Hypertension in exodontia (2) /certified fixed orthodontic courses by Indian dental academy

HYPERTENSION IN HYPERTENSION IN EXODONTIA EXODONTIA

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CONTENTS CONTENTS Definition Definition Types Types Causes Causes Signs Signs Target organ diseases Target organ diseases Investigation Investigation General ManagementGeneral Management Dental aspect of hypertension Dental aspect of hypertension Conclusion Conclusion ReferencesReferences


Increase in blood pressure Increase in blood pressure

It is a It is a traitor opposed to a specific diseasetraitor opposed to a specific disease and represent a and represent a quantitativequantitative rather than a rather than a qualitative deviation from the norm, hence qualitative deviation from the norm, hence any definition is arbitrary any definition is arbitrary


Types Types

Hypertension

Essential Secondary White collar


Causes

Idiopathic

Secondary


Idiopathic Idiopathic 40-60% is genetic factor 40-60% is genetic factor High salt intake High salt intake Heavy consumption of alcoholHeavy consumption of alcohol Obesity Obesity Lack of exercise Lack of exercise Impaired intrauterine growth Impaired intrauterine growth Stress Stress


Secondary Secondary AlcoholAlcohol Pregnancy Pregnancy Renal disease Renal disease

– Renal artery disease Renal artery disease – Pyelonephritis Pyelonephritis – Glomerulonephritis Glomerulonephritis – Polycystic disease Polycystic disease – Post trasnplant Post trasnplant

Coarctation of aorta Coarctation of aorta www.indiandentalacademy.comwww.indiandentalacademy.com

Secondary causes contd.Secondary causes contd. Endocrine disease Endocrine disease

– Pheochromocytoma Pheochromocytoma – Cushings syndrome Cushings syndrome – Acromegaly Acromegaly – ThyrotoxicosisThyrotoxicosis– Hyperaldosteronism Hyperaldosteronism

Cerebral disease Cerebral disease – Cerebral oedema (stroke, head injuries & tumours)Cerebral oedema (stroke, head injuries & tumours)

Drugs Drugs – Oral contraceptives Oral contraceptives – Streroids Streroids – NSAIDSNSAIDS


Signs Signs Paroxysmal headache Paroxysmal headache Palpitation Palpitation Sweating Sweating BreathlessnessBreathlessness Angina Angina


Target organ disease

Blood vessels

Central nervous system

Retina

Heart

Kidneys

Malignant or accelerated phase hypertension


Blood vessels

Larger arteries Smaller arteries


Larger arteries Larger arteries (Over 1mm in dia)(Over 1mm in dia)

↓↓Internal elastic lamina is thickened Internal elastic lamina is thickened

↓↓Smooth muscle hypertrophy Smooth muscle hypertrophy

↓↓Fibrous tissue is depositedFibrous tissue is deposited

↓↓Vessels dilate become tortous, walls become less compliantVessels dilate become tortous, walls become less compliant

↓↓Aggravates hypertension by increasing peripheral vascular Aggravates hypertension by increasing peripheral vascular

resistance resistance ↓↓

Aortic aneurysm & dissection, coronary & cardiovascular Aortic aneurysm & dissection, coronary & cardiovascular disease, renal failure disease, renal failure www.indiandentalacademy.comwww.indiandentalacademy.com

Smaller arteries Smaller arteries ↓↓

Hyaline arteriosclerosis in the wall Hyaline arteriosclerosis in the wall ↓↓

Lumen narrows Lumen narrows ↓↓

aneurysm develops aneurysm develops ↓↓

Aggravates hypertension by increasing peripheral Aggravates hypertension by increasing peripheral vascular resistance vascular resistance

↓↓Aortic aneurysm & dissection, coronary & Aortic aneurysm & dissection, coronary &

cardiovascular disease, renal failure cardiovascular disease, renal failure


Central nervous system Central nervous system Stroke due to cerebral hemorrhage or infarction Stroke due to cerebral hemorrhage or infarction

Carotid atheroma & transient cerebral ischemia attacks Carotid atheroma & transient cerebral ischemia attacks are common are common

Subarachnoid haemorrhage Subarachnoid haemorrhage

Symptoms are Symptoms are – Disturbance of speech or vision Disturbance of speech or vision – Paraesthesia Paraesthesia – Disorientation Disorientation – Fits & loss of consiousnessFits & loss of consiousness

Neurologial deficit is usually reversible if the Neurologial deficit is usually reversible if the hypertension is controlled hypertension is controlled www.indiandentalacademy.comwww.indiandentalacademy.com

Retina Retina Central retinal vein thrombosis occurs Central retinal vein thrombosis occurs

Micro aneurysm also occurs Micro aneurysm also occurs


Heart Heart

High blood pressure

Left ventricular hypertrophy (atrial f ibri l lation) Left ventricular fai lure


Kidney Kidney ProteinuriaProteinuria

Progressive renal failure by damaging the Progressive renal failure by damaging the renal vasculature renal vasculature


Malignant or accelerated phase Malignant or accelerated phase hypertension hypertension

This rare condition may complicate This rare condition may complicate hypertension of etiology and is hypertension of etiology and is characterized by damage with necrosis in characterized by damage with necrosis in the walls of small arteries & arterioles the walls of small arteries & arterioles


Investigations

For al l patients Selected patients


Investigations for all patients Investigations for all patients Urine analysis for blood, protein and Urine analysis for blood, protein and

glucose glucose Blood urea, electrolyte, and creatinine Blood urea, electrolyte, and creatinine Blood glucose Blood glucose Serum total and high density lipoprotien Serum total and high density lipoprotien 12 lead ECG 12 lead ECG


Investigations for selected patients Investigations for selected patients

Chest radiographChest radiograph Ambulatory BP recording Ambulatory BP recording EchocardiogramEchocardiogram Renal ultrasound Renal ultrasound Renal angiography Renal angiography Urinary catecholamines Urinary catecholamines Urinary corstiol and dexamethasone supressing Urinary corstiol and dexamethasone supressing

test test Plasma renin activity and aldosterone Plasma renin activity and aldosterone


Management

Non-drug therapy Drug therapy


Non drug therapy Non drug therapy Correct obesity Correct obesity Reducing alcohol intake Reducing alcohol intake Restricting salt intake Restricting salt intake Regular physical exercise Regular physical exercise Increasing consumption of fruits and Increasing consumption of fruits and

vegetables vegetables Quitting smoking Quitting smoking Eating oily fishEating oily fish


Drug therapy Drug therapy ß ß adrenoreceptor blockers adrenoreceptor blockers

– Metaprolol (100-200mg/day)Metaprolol (100-200mg/day)– Bisoprolol (50-100mg/day)Bisoprolol (50-100mg/day)– Atenolol(50-100mg/day)Atenolol(50-100mg/day)– Labetalol (200-2.4g/day)Labetalol (200-2.4g/day)

Possible oral effectsPossible oral effects– Dry mouth Dry mouth – Lichenoid reactions Lichenoid reactions – Paresthesia with labetalol Paresthesia with labetalol

Other adverse effects Other adverse effects – Contraindicated in asthmaContraindicated in asthma– Avoid in heart failure/block Avoid in heart failure/block – Muscle weaknessMuscle weakness– Lassitude Lassitude – Disturbed sleep Disturbed sleep www.indiandentalacademy.comwww.indiandentalacademy.com

Vasodilators Vasodilators Prazosin (0.5-20mg/day)Prazosin (0.5-20mg/day) Indoranmin (20-100mg/day)Indoranmin (20-100mg/day) Hydralazine (25-100mg/day)Hydralazine (25-100mg/day) Minxidil (10-50mg/day)Minxidil (10-50mg/day) Adverse effects Adverse effects

– Headache Headache – HypertrichosisHypertrichosis– oedemaoedema


ACE inhibitorsACE inhibitors– Captopril (25-75 mg/BD)Captopril (25-75 mg/BD)– Enalapril (20mg/day)Enalapril (20mg/day)– Ramipril (5-10 mgdaily)Ramipril (5-10 mgdaily)– Lisinopril (10-20 mg /day)Lisinopril (10-20 mg /day)

Possible oral effects Possible oral effects – Sinusitis Sinusitis – Lichenoid reactionLichenoid reaction– Loss of taste Loss of taste – Burning sensation Burning sensation

Adverse effects Adverse effects – Sudden fall in bp Sudden fall in bp – Impair renal function Impair renal function – Cough Cough – Angioedema Angioedema


Calcium channel blockers Calcium channel blockers – Nifidipine (30-90mg/day)Nifidipine (30-90mg/day)– Verapamil (240mg/day)Verapamil (240mg/day)

Oral effects Oral effects – Gingival hyperplasia Gingival hyperplasia – SalivationSalivation

Adverse effects Adverse effects – Headache and flushing Headache and flushing – Swollen legs Swollen legs


Dental aspects Dental aspects Pre operative evaluationPre operative evaluation

Management guidelines Management guidelines


Pre operative evaluation Pre operative evaluation Determine Determine

– Electrolyte Electrolyte – Creatinine Creatinine – BUN BUN – Hypokalemia Hypokalemia

Asses the complications Asses the complications – Status of therapyStatus of therapy– Papilledema Papilledema – Retinal hemorrages Retinal hemorrages – Heart failure Heart failure – Cardiac enlarge maent Cardiac enlarge maent


Management guidelines Management guidelines Untreated mild or moderate hypertensionUntreated mild or moderate hypertension

– Diastolic- 90-110 mg hg Diastolic- 90-110 mg hg – Bp should be monitored Bp should be monitored – Medication should be used pre and post Medication should be used pre and post

operatively operatively

Controlled hypertnsion Controlled hypertnsion – Therapy should be maintained untill the night Therapy should be maintained untill the night

before surgery before surgery – Medication to be known to anaesthesiologist Medication to be known to anaesthesiologist – Potassium preoperative to be given Potassium preoperative to be given www.indiandentalacademy.comwww.indiandentalacademy.com

Moderate to severe hypertension Moderate to severe hypertension – Diastolic greater than 110mm hg Diastolic greater than 110mm hg – Rapidly acting agents can be given Rapidly acting agents can be given – Emergency- nitriprusside or nitroglycerine Emergency- nitriprusside or nitroglycerine – I.v methydopa or diazoxide I.v methydopa or diazoxide – Oral prazosin or clonidine Oral prazosin or clonidine


General anesthesia General anesthesia Contraindications Contraindications

– Severe hypertension Severe hypertension – Cardiac failure Cardiac failure – Coronary / cerebral artery insufficiency Coronary / cerebral artery insufficiency – Renal insufficieny Renal insufficieny

Best treated under LA Best treated under LA Diuretics should be stopped before Diuretics should be stopped before

surgery surgery


Conclusion Conclusion


References References



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